Care providers have the opportunity to initiate member screenings and lab work without delay. To help detect and manage health conditions in a timely manner, set a proactive course for member wellness throughout the year. Early and routine screenings align with our commitment to comprehensive, preventive healthcare, contributing to better health outcomes for all.

Broader access for members and more options for care providers

Both our preferred national labs, LabCorp and Quest Diagnostics, are in-network for our Commercial and Medicare plans. This expansion not only broadened the spectrum of diagnostic options available but also enhanced convenience for members through increased specimen draw locations.

Our expanded network benefits members and care providers through:

• Increased convenient testing locations and appointment scheduling: online appointment scheduling, conveniently located patient service centers, and timely access to results
• Expanded testing options, including specialty testing expertise: broad menu of routine and specialized tests, including molecular, genetic, and genomic testing
• Streamlined workflow and enhanced efficiency: easy-to-use lab management services for ordering tests and supplies, scheduling a specimen pickup, and tracking order status

We encourage you to share this update with your patients and leverage the expanded network for efficient and effective care delivery.

We are committed to helping patients more easily access the care they need. You can find our participating laboratories — including LabCorp and Quest Diagnostics — in our online provider directory at Find Care.

To align with the Centers for Medicare & Medicaid Services (CMS) guidance, we are updating our claims editing system regarding claim submissions for global surgical procedures. This update will ensure that reimbursements are accurately processed for clearly distinct surgical procedures performed during the postoperative period, excluding re‑operations or complications from treatment. These changes will be effective for dates of service starting on July 1, 2025.

Updated reimbursement eligibility criteria for global surgical procedures

• Claim lines will not be eligible for reimbursement when a 0-day, 10-day, or 90-day global surgical procedure is submitted during the postoperative period of a prior 10-day or 90-day procedure by the same provider for the same member unless it is a distinct procedure.
• The logic reviews the diagnoses reported to the seventh digit.
  If the diagnoses are different, the claim line will be allowed; if the diagnoses are the same, the claim line will not be allowed.
• Modifiers 58, 78, and 79 or site modifiers E1‑E4, F1‑F9, FA, T1‑T9, TA, LM, RI, LC, LD, RC, RT, and LT are appropriate to identify unrelated procedures.

Example

The provider reports procedure code 68761‑E2 and diagnosis code H04.123 with the date of service of January 10, 2025. If the same provider reports procedure code 68760‑E2 and diagnosis code H04.123 with a date of service of January 16, 2025, the claim line for January 16, 2025, will not be allowed since the same site modifier and diagnosis are present as the procedure 10 days prior.

How to Initiate a Claims Payment Dispute

If you believe a claim reimbursement decision should be reviewed, follow the claims payment dispute process outlined in your provider manual, which is available at https://www.anthem.com/provider/individual-commercial/reimbursement.

Contact us

In accordance with CMS guidelines, contracted Medicare Advantage care providers for special needs plans (SNP) must complete our annual Model of Care training. Providing a detailed overview of SNP, this training highlights cost sharing; data sharing; participation in the Interdisciplinary Care team; where to access the member’s health risk assessment results; plan of care and benefits coordination; and ensures the specific care needs of your patients, our members, are met.

To access the training, go to the link below:
https://www.anthem.com/content/dam/digital/docs/provider/commercial/ma/train/ABCBS-CR-070929-25.pdf

We are excited to announce the launch of the Availity Essentials Provider Overpayments application in July 2025. The Provider Overpayments application is a robust tool for improving digital communication in managing claim overpayments. It offers care providers a streamlined and efficient way to handle notifications, inquiries, disputes, and resolutions of overpayments directly through the Availity website.

Benefits of the Availity Overpayments application:

• Comprehensive management: Access a user‑friendly platform to help you efficiently oversee overpayment processes, from initiation to resolution.
• Intuitive interface: Navigate easily through five overpayment statuses: Action Required, Inquired, Disputed, Resolved, and Closed, with overpayment details displayed as unique cards.
• Enhanced communication: Benefit from integrated messaging functions and document uploads to facilitate clear communication and documentation.
• Training and support: Training resources and support are available to assist you in maximizing the use of this tool. All application documentation/demos are available after logging into Availity Essentials.

If you experience technical issues while logging in or using Essentials, contact Availity Client Services at 800‑AVAILITY for immediate assistance.

Training and demo schedule:

We look forward to helping you enhance operational efficiencies and improve claim overpayment management. For access to Availity Essentials learning resources, follow these two easy steps:

1. Log in to Availity Essentials.
2. Select the Help and Training menu.

Thank you for your continued partnership.

We are excited to announce two new interactive training courses for uploading rosters through the Availity platform. Dive into these two 20‑minute sessions and master the roster upload process with confidence.

The Provider Roster Upload via Availity course will guide you through uploading rosters, troubleshooting errors, and downloading your data. The Roster Automation Standard Template course offers training on using a roster template to enhance compatibility and streamline the submission process.

Don't miss this opportunity to unlock valuable insights. Visit https://Availity.com and navigate to Payer Spaces > Payer Tile > Resources to access the latest Roster Automation Standard Template and Roster Submission Guide.

Access all training courses on the Digital Solutions Learning Hub.

Understanding how to update claims to bill inpatient and outpatient services accurately ensures prompt reimbursement, improves quality reporting, and increases patient satisfaction by mitigating unexpected costs. Please use the guidance below.

Replacement of inpatient bill types

When a claim is mistakenly billed as an inpatient bill type, it must be replaced using the ‘replacement bill type’ xx7. To correctly replace an inpatient bill type, the replacement must match the same bill type category:

• Replace x11 with x17
• Replace x31 with x37
• Do not replace x11 with x37, or x17 with x31.

Changing between inpatient and outpatient bill types

To change billing from inpatient to outpatient or from outpatient to inpatient, follow these steps:

1. Void the incorrect claim using ‘frequency type 8’ to avoid errors and overlaps.
2. Create a new claim submission labeled ‘frequency type 1’ to represent the correct billing type.

Contact your network manager or provider relationship management representative with any questions.

Did you know 40% to 50% of patients are non‑adherent to their medications for chronic conditions, leading to 100,000 preventable deaths and $100 to $300 billion in avoidable medical costs per year?

Medications are the primary intervention in treating and preventing disease. For most conditions, medications need to be taken 80% or more of the time to see an improvement in clinical outcomes.

Understanding the potential challenge

Medication adherence is not just about patients remembering to take their pills. Adherence is a multifaceted issue influenced by several factors, which can include:

• Adherence challenges such as cognitive impairment, history of non‑adherence, and confusion or misunderstandings.
• Concerns for the fear of side effects, perceived lack of benefit, and complex medication regimens.
• Logistical or financial Issues such as transportation difficulties or high medication costs.

Implementing solutions

Identifying patients with adherence issues can be challenging. We recommend incorporating the following strategies into your practice:

• Discuss adherence with patients at each appointment using open‑ended questions.
• Analyze claims or non‑adherence reports to find at‑risk patients.
• Use electronic health records for proactive identification of at‑risk patients.

Tailored and proactive approaches

Once identified, it is essential to tailor solutions to each patient’s unique needs:

• Simplify regimens using once‑daily doses and 90‑day supplies with refills.
• Educate patients by clearly explaining medication benefits and risks.
• Streamline prescribing with real‑time prescription benefits.
• Reduce pharmacy visits using e‑prescribe to CarelonRx for home delivery.

Spotlight on success

When patients struggle with controlling their condition, consider medication non‑adherence as a potential reason. Care providers can significantly improve patient outcomes and reduce healthcare costs by employing these strategies.

Effective on July 26, 2025, the following Carelon Medical Benefits Management Clinical Appropriateness Guideline updates will be adopted for HealthKeepers, Inc. This article is to communicate the plan adoption of these guidelines. Existing prior authorization requirements have not changed. In the event a prior authorization requirement for these services will be implemented, a separate notice will be distributed before the addition of any prior authorization requirements.

The following guideline updates have a publish date of July 26, 2025:

• Genetic Testing
• Chromosomal Microarray Analysis
• Pharmacogenomic Testing
• Whole Exome Sequencing and Whole Genome Sequencing
• Musculoskeletal
• Interventional Pain Management

You may access and download a copy of the current and upcoming guidelines here.

Please share this notice with other members of your practice and office staff.

Effective on June 20, 2025, the following Carelon Medical Benefits Management Clinical Appropriateness Guideline updates will be adopted for HealthKeepers, Inc. This article is to communicate the plan adoption of these guidelines. Existing prior authorization requirements have not changed. In the event a prior authorization requirement for these services will be implemented, a separate notice will be distributed before the addition of any prior authorization requirements.

Please share this notice with other members of your practice and office staff.

The following guideline updates have a publish date of March 23, 2025:

• Genetic Testing:
• Somatic Tumor Testing

You may access and download a copy of the current and upcoming guidelines at https://guidelines.carelonmedicalbenefitsmanagement.com.

Summary: The Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem. These policies were developed, revised, or reviewed to support clinical coding edits.

Visit our Clinical Criteria page to find specific policies. If you have questions or need additional information, please email us.

Please see the explanation/definition for each category of Clinical Criteria below:

• New: newly published criteria
• Revised: addition or removal of medical necessity requirements, new document number

Please share this notice with other members of your practice and office staff.

Note:

• The Clinical Criteria listed below apply only to the medical drug benefits contained within the member’s medical plan. This does not apply to pharmacy services.
• This notice is meant to provide information on new or revised criteria that have been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.

Effective for dates of service on and after September 1, 2025, the following Clinical Criteria were developed and might result in services that were previously covered but may now be found to be not medically necessary.

Anthem will manage prior authorization of these specialty pharmacy drugs. Drugs used for the treatment of Oncology will still require prior authorization by Carelon Medical Benefits Management, Inc., a separate company. This applies to PPO and HMO members.

Access the Clinical Criteria website for more information.

Congenital syphilis rates have been on the rise, despite advances in healthcare. The need for heightened awareness and proactive measures from care providers is important to prevent severe effects in infants.

What is congenital syphilis?

Congenital syphilis occurs when the bacterium Treponema pallidum is transmitted from an infected mother to her baby during pregnancy or delivery. The consequences of untreated syphilis are significant, leading to potential stillbirth, neonatal death, and long-term neurological and developmental issues in affected infants.

Care providers should take the following steps for prevention:

1. Routine testing: We encourage regular syphilis testing for pregnant women at the first prenatal visit, in the third trimester, and at delivery.
2. Education and counseling: Educate expectant women on the risks of syphilis and the importance of treatment and prevention. Encourage open communication about sexual health.
3. Timely and appropriate treatment: Ensure immediate treatment of syphilis in pregnant patients with the recommended penicillin regimen to prevent transmission to the infant.
4. Follow‑up and support: Maintain active follow‑up for treated patients to ensure completion of therapy and serological response. Offer support services to help manage the needs of vulnerable populations.
5. Collaborative efforts: Work in collaboration with local health departments and community organizations to promote awareness, screening, and prevention initiatives.

Congenital syphilis, which increased by 755% from 2012 to 2021 in the U.S (Practice Advisory, 2024), requires a coordinated effort from all stakeholders in healthcare. This preventable condition can severely affect infants; timely screening and treatment could have prevented 88% of cases in 2022 (Practice Advisory, 2024). Your role as a healthcare provider is vital in this effort.

Please do not hesitate to reach out to us if you have questions or need additional resources to support your practice in preventing congenital syphilis. You can email questions to maternalchildhealth@anthem.com.

Thank you for your dedication and commitment to providing quality care to our members.

Reference

Practice Advisory. Screening for Syphilis in Pregnancy. The American College of Obstetrics and Gynecologists (2024): https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2024/04/screening-for-syphilis-in-pregnancy

Utilization management (UM) decisions for Anthem HealthKeepers Plus members are based on the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service, or care. We do not make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in underutilization. Our medical policies are available on our provider website at https://providers.anthem.com/va > Resources > Policies, Guidelines & Manuals, or at this link.

You can request a free copy of our UM criteria from our Medical Management department. To access UM criteria online, go to link. Providers can discuss a UM denial decision with a physician reviewer by calling us toll free at the number listed below.

Our utilization management (UM) policies are designed to optimize clinical decision‑making and resource allocation so members can access efficient, cost-effective services. Please review the information below regarding the UM criteria decision process.

To submit preapproval requests:

• Online: Go to Availity Essentials at https://Availity.com
• Phone: 800‑901‑0020
• Fax: 800‑964‑3627

To discuss UM decisions or preapproval requests with a physician reviewer, contact Provider Services at 800-901-0020, Monday through Friday, from 8:30 a.m. to 5 p.m. ET. Secured voicemail is available during off-business hours; a clinical professional will return your call within the next business day. Our staff will identify themselves by name, title, and organization when initiating or returning calls regarding UM issues.

We believe that the first step in delivering quality healthcare is cooperation between patients and care providers to clearly understand the member’s rights and responsibilities. Please review the Members’ Rights and Responsibilities section of the provider manual at https://providers.anthem.com/va to stay current and help keep members informed.

If you have questions, contact Provider Services at 800‑901‑0020.

We understand that managing an illness can be challenging for our members. Understanding test results, acquiring treatment resources, and connecting with the right people for support can be overwhelming.

Program summary:

• Support — The program offers comprehensive assistance throughout the member’s treatment plan.
• Interdisciplinary team — Case managers work alongside clinicians and resource professionals to assist members, families, PCPs, and caregivers.
• Education and empowerment — The program educates members on building self‑management skills and understanding health concerns and care choices.
• Transition assistance — The program aids in transitions across care levels, preparing patients and caregivers for informed healthcare decisions and goals.

Referral process:

• Member referral: Members can refer themselves or family members by calling the Member Services number on the back of their ID card.
• Physician referral: By phone or online.

If you have questions about this communication, contact Provider Services at 800‑901‑0020. The Case Management business hours are Monday through Friday from 8 a.m. to 6 p.m. ET.